Papers

Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering corticosteroids in asthma

David Brocklebank, specialist registrar in respiratory medicine, ^a John Wright, consultant in clinical epidemiology and public health, ^a Christopher Cates, general practitioner, ^b on behalf of the National Health Technology Assessment Inhaler Review Group.

^a Bradford Hospitals NHS Trust, Bradford Royal Infirmary, Bradford BD9 6RJ, ^b Manor View Practice, Bushey Health Centre, Bushey, Hertfordshire WD2 2NN

Correspondence to: J Wright john.wright{at}bradfordhospitals.nhs.uk

Objective: To determine the clinical effectiveness of pressurised metered dose inhalers (with or without spacer) compared with other hand held inhaler devices for the delivery of corticosteroids in stable asthma.
Design: Systematic review of randomised controlled trials.
Data sources: Cochrane Airways Group trials database (Medline, Embase, Cochrane controlled clinical trials register, and hand searching of 18 relevant journals), pharmaceutical companies, and bibliographies of included trials.
Trials: All trials in children or adults with stable asthma that compared a pressurised metered dose inhaler with any other hand held inhaler device delivering the same inhaled corticosteroid.
Results: 24 randomised controlled trials were included. Significant differences were found for forced expiratory volume in one second, morning peak expiratory flow rate, and use of drugs for additional relief with dry powder inhalers. However, either these were within clinically equivalent limits or the differences were not apparent once baseline characteristics had been taken into account. No significant differences were found between pressurised metered dose inhalers and any other hand held inhaler device for the following outcomes: lung function, symptoms, bronchial hyper-reactivity, systemic bioavailability, and use of additional relief bronchodilators.
Conclusions: No evidence was found that alternative inhaler devices (dry powder inhalers, breath actuated pressurised metered dose inhalers, or hydrofluoroalkane pressurised metered dose inhalers) are more effective than the pressurised metered dose inhalers for delivery of inhaled corticosteroids. Pressurised metered dose inhalers remain the most cost effective first line delivery devices.